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Eating disorders when to intervene and what to do 2011 Conference for General Practice M. Louise Webster Child and Adolescent Psychiatrist Starship Children’s Hospital and University of Auckland How much of a problem? Children’s book sparks body image concerns.19 Aug 2011 – Sydney Morning Herald ( 8/19/2011 6:17:37 AM -08:00 ) ... The children's picture book, "Maggie Goes on a Diet," has come ... The mother of a London teenager who died after anorexia "ravaged" her body today condemned a diet book aimed at ... www.nzherald.co.nz/health/news/article.cfm?c_id=204... - Cached 8 Mar 2009 – Health officials have spent nearly $750000 sending anorexic teenagers to Australia for treatment because New Zealand doesn't have enough ... www.dailymail.co.uk/.../Malissa-Jones-Britains-fattest-teenagerbattling- ... 4 May 2011 – A woman who was once Britain's fattest teenager is now battling with anorexia after her life was turned upside down by a gastric bypass ... What we will cover • • • • • • Diagnostic criteria – strengths and limits Epidemiology Outcomes Screening and assessment in primary care Who to admit Management in primary care setting Diagnostic criteria • AN - Anorexia nervosa • BN - Bulimia nervosa • EDNOS - Eating disorder not otherwise specified Anorexia Nervosa DSM-IV 1. Refusal to maintain body weight at or above 85% of expected, or failure to make expected weight gain during period of growth 2. Intense fear of gaining weight or becoming fat even though underweight 3. Disturbed body image – denial that low weight is a problem 4. Amenorrhoea (in post menarcheal females) Subtypes: restricting and binge/purging type Bulimia Nervosa DSM-IV • Recurrent episodes of binge eating – 2x weekly for at least 3 months • Recurrent inappropriate compensatory behaviour – vomiting, laxatives, fasting • Self worth contingent on shape and weight • Bulimic symptoms do not occur exclusively in context of AN Subtypes: purging and non-purging EDNOS • Eating disorder symptoms that do not meet threshold criteria for AN or BN • Often as severe and long lasting as classical conditions with same risks • Is the most common diagnosis Problems with diagnostic criteria for younger adolescents and children • Smaller weight loss may be detrimental – physiological decompensation after relatively small losses • Often unable to articulate fears of fatness as a driver for weight loss or food avoidance – observed behaviour is a better guide • Less able to appraise self-worth, body shape and risk • Amenorrhea – Prepubertal children – how do you check veracity – OC use How common • Incidence AN 4-8 per 100,000 per year • Lifetime prevalence of AN in women = 2% • Point prevalence rates – AN 0.3% – BN 1.0% – EDNOS 3% • Increase between 1930s and 1970s, more stable since then • Onset mostly in adolescence • 10% of cases in males Anorexia Nervosa • Third most common chronic illness in adolescent females (after asthma and obesity) • Highest mortality rate of any psychiatric disorder – 10 - 20% die within 20 years (½ malnutrition, ½ suicide) • 12X increased mortality cw healthy adolescents Who gets an eating disorder? • Girls who diet – 18X risk for severe dieters – 5X risk for moderate dieters (account for 2/3 of new ED cases) • Young women with other psychiatric problems – 7X increased risk (Patton 1999) • Trying to look like people in the media • Younger children/adolescents with a family history of eating disorder (Field 2008) General trends in community • Increased focus in young people on weight • 14 -16 yr old girls (Grigg 1996) – – – – 77% wanted to lose weight 57% unhealthy dieting 33% disordered eating 12% distorted body image • 8 year old girls (Robinson 2001) – 35% unhappy with their weight – 24% dieting Trends in AN • Younger age of onset – pre-pubertal/early adolescent increasing • Previously overweight young people who lose weight rapidly – BMI may be normal or high but will be metabolically and physiologically unstable • Increased awareness of male eating disorder spectrum – Extreme exercise, body-builders, subst use Prognosis in those treated for AN • • • • Average duration of illness is 5-6 years Mortality 10-20% (improving) 47% full recovery (all ages) Younger onset and short duration of symptoms lead to better outcomes – 80% adolescents treated for AN achieve normal weight and eating Outcomes for community samples • • • • • General Practice sample (van Son 2010) ½ referred for mental health care 50-60% AN and BN recovered at 5yrs Age <20 yrs = better outcome Those with AN plus binge/purge – took longest to recover – had highest psychiatric comorbidity Adolescent community sample • 1 in10 girls 15 – 17 years had EDNOS • 15% still had an eating disorder 10 years later • Those with an adolescent eating disorder had increased rates after 10 years of:– Depressive and anxiety syndromes – Underweight – Substance misuse – Incomplete education (Patton 2008) Screening and assessment How do people with eating disorders present to you • Seldom because they think they have a problem • Usually because parents/friends/family are concerned about weight loss and altered eating pattern • May present with complications of weight loss – fainting, general malaise, infertility • May be an incidental finding while in for routine matter Screening questions Simple screening questions as good as standardised instruments in community setting • Have you ever had anorexia? • Has anybody ever suspected that you have an eating disorder? • Have you ever vomited or used laxatives, diuretics, or enemas for weight loss or weight control? (Keski-Rahkonen 2006) Early warning signs in the context of dieting • • • • • • • • Constant focus on dieting, food, exercise Insisting on having different meals from family Insisting on eating alone Suddenly becoming vegetarian/vegan/dairy-free Stressed if unable to exercise, covert exercise Frequent weighing Frequent visits to bathroom after meals Social withdrawal, low mood, irritable (adapted from Yeo 2011) If you suspect an eating disorder, assessment needs to include:• • • • • • • • • • History of weight loss and growth History of dieting or food restriction History of exercising History of purging Menstrual history Family history and circumstances Measurement of height and weight Physical examination Standard psychiatric assessment Standard investigations Children vs Adults • Higher risk rapid medical deterioration – After relatively small weight loss – If stop drinking and get dehydrated • Risk of potentially irreversible effects on physical and emotional development • Linear Growth impairment • Pubertal Delay • BMI less useful, can be normal even when quite malnourished, use BMI centiles Assessment – corroborate with parents/family also • History of weight loss – initial weight, rate of loss, highest and lowest weights, current weight • History of dieting or food restriction – amounts and types of food eaten, actual amounts eaten each meal, food hiding, beliefs about food types. • Fluid restriction • Exercise/activity levels hours per day – Covert exercise – Current participation in elite sports eg gymnastics, ballet, athletics • Bulimic symptoms – Bingeing (high calorie foods eaten rapidly in a short space of time) – Vomiting – Laxative abuse – Under-dosing of insulin in diabetics Physical history • Menstrual history – onset, LMP – OC use • Other physical symptoms/illnesses • Energy levels, cold tolerance, fainting BMI and ideal body-weight • BMI = weight (kg) ÷ (height x height) (metres) • Use age adjusted BMI percentile chart to assess where young person is and to calculate target weight – These can be down-loaded from CDC website – Compare with previous growth trajectory • In younger children/adolescents we use expected height not actual height Typical growth chart with severe AN Examination • • • • • • • Height, accurate weight, BMI, BMI centile HR, body temperature, lying and standing BP Capillary refill Peripheral cyanosis Pubertal status Assessment of mental state Stigmata of binging/purging/self harm (roughness on knuckle of index finger, • enlargement parotid glands, cutting etc on arms) • Peripheral or sacral oedema Mental state exam - look especially for • Baggy clothing to disguise weight loss, or clothes that are inadequate for warmth • Physical over-activity and restless • Talk and thought content focused on food, fear of fatness • Distorted body image – – sees self as fat despite low/normal weight – no actual psychotic symptoms – beliefs about weight and food may be fixed and intense MSE • Mood maybe low due to malnutrition or to co-morbid depressive illness – Must check for suicidal ideation • Insight usually impaired regarding own physical state and the need to gain weight • Maybe angry or resistant to being assessed, minimising parents concerns Aim to • Feed back findings from physical examination • Establish weight monitoring and a plan to follow if weight falls • Discuss psychiatric risk if very depressed or suicidal • Give young person and family basic information about nature, course and treatment of eating disorders Investigations Early stages (expect normal lab results) • FBC + ESR • U & E, Creat, Ca, Mg, Phosphate, random blood glucose • LH, FSH, oestradiol (or testosterone if male) If more advanced/severe weight-loss add in • Bicarb & pH on venous gas (metabolic alkalosis may indicate vomiting) • LFTs • Calcium, Phosphate, Magnesium • TFTs • ECG – QT & PR interval (identify risk of sudden death) • Urinalysis including pH, specific gravity and ketones (pH high and specific gravity low if water loaded) So what next • Medically unstable – admit medically to paediatric service (under 15 years) or adult • Moderate to severe but still medically stable – refer acutely to CAMHS, CMHC, or Specialist Eating Disorder Service – Still have to manage then while waiting for an appointment • Mild or early weight-loss – manage in primary care with regular monitoring and guidance to parents Starship Admission Criteria ANY of the following: 1. Life-threatening weight loss 2. Acute medical complications of malnutrition 3. Acute food refusal 4. Significant dehydration 5. Hypoglycaemia 6. Electrolyte imbalance 7. Physiological instability 8. Abnormal ECG 9. Significant co-morbid psychiatric states 10. Failure to gain weight despite max outpatient Rx Starship General Paediatric Guidelines • Life-threatening weight loss – – • Total body weight < 75% expected (for height) Acute weight loss of 15-20% in 3 months Electrolyte imbalance – – Hypokalaemia (<3.0 mmol/L) Hypophosphataemia (anything below normal range) • Physiological instability – – – – Bradycardia - HR < 50/min (check several times) Hypotension - Systolic BP < 80 mmHg Hypothermia - Temp <35.5 C Significant postural drop in BP (> 20mmHg) or rise in HR (increase by > 30 bpm) • Abnormal ECG – Arrhythmia – Diminished amplitude of QRS complex and T waves – Prolonged QTC (>0.44) – (see ECG guideline) Important role for GP in managing • Disordered eating • Problematic dieting • Early eating disorders AND • Ongoing physical monitoring of patients under the outpatient care of CAMHS and CMHCs Primary care role • Weekly monitoring of weight and physiological parameters • Psycho-education about – the effects of starvation on the body – Importance of a balanced diet including need for carbohydrate, protein, and fats – Importance of regular meals to prevent starvation and binge/purge pattern of eating • Support for patients to address these issues – Must involve parents for children/adolescents – Spouse/friends/family for adults Focus of AN treatment for young people is family-based • Supporting parents to get their child to eat enough to regain a health weight • Close supervision of – Regular meals and snacks – Appropriate amounts and types of food – Activity levels • Stand firm and working together as parents despite distress and protest • Is delivered by trained therapists in Specialist eating disorder services and CAMHS over 6-12 months (Known as ‘Maudsley Model’ family therapy or Family based therapy) “Food is an important part of a balanced diet” - Fran Lebowitz (Author) Therapy for children and adolescents with AN • Little evidence that individual therapy is helpful in the acute stages of AN • Once weight recovery has occurred, CBT for anxiety (OCD) maybe useful • Antidepressants for low mood are not helpful at a very low weight – wait until weight is normal Food - ask parents to take control • Keep an accurate record of exactly what and how much their child is eating – ‘normal’ amounts of food will not be sufficient to reverse weight loss • Young person needs to eat usual family foods – ‘maintenance’ plus lost weight – Aim for 250 – 500g/week weight gain – May need to involve community dietician You may need to get parents to • Stop all activities that require energy until back to a normal weight – Sports, dance, athletics, swimming • If the young person is still losing weight or failing to regain weight – Keep the young person home from school – Stop all outside activities – Monitor for covert exercise/purging behaviours Re-feeding Syndrome rare in community settings • Think of this if – At a very low weight or sudden rapid weight loss – Sudden re-feeding without supplementary phosphate • Sudden death (first weeks) Hypophosphataemia Hypothermia Hypoglycaemia Prolonged QTc • Delirium (second two weeks) Remember • Parents and families don’t cause AN • Parents find it hard with previously compliant well-behaved high-achieving ‘good’ children, to stand firm • Treating AN like any other chronic illness reduces guilt and blame – ‘what would you do if your child had diabetes and didn’t want their insulin’ Anorexic behaviours and emotions • • • • • • Impaired cognitive function Abnormal emotional processing Change in personality Low mood, irritable Obsessive and anxious These behaviours are usually a result of malnutrition and the illness TREATMENT = FOOD & SUPPORT Antidepressants ineffective Bulimia Nervosa • Mainstay of treatment is Cognitive Behavioural Therapy (CBT) – group or individual – Aims to normalise eating patterns and reduce binge/purging – Diary record of eating, binging, purging – Aim for regular 3 meals/day – Modification of maladaptive thought patterns • Important primary care role of monitoring general health – Regular electrolytes if vomiting regularly – K+ Na For patients who are reluctant to accept treatment • Family involvement and support – Critical in children and adolescents – Still extremely important in adulthood • Motivational interviewing • The immense value of an ‘ongoing relationship’ with the GP • Use of Mental Health Act if patients eating disorder is causing significant immediate risk to their well-being Take home points • Think of eating disorders in adolescents and children, especially those who are dieting • Accurate height and weight – Use BMI percentile charts for the young • Admit acutely if medically unstable • The primary treatment is FOOD • Support parents to take control early on and reverse weight-loss trend • Monitor weekly Resources • Starship Hospital Website: Anorexia Nervosa guidelines • Yeo M, Hughes E. (2011) Eating Disorders: Early identification in general practice Australian Family Physician Vol 40 (3) March pp108-111